Ergot alkaloid, 5-HT1B/1D and alpha-adrenoceptor agonist
ATC code: N02CA01 (Dihydroergotamine)
Brand names
Migranal, D.H.E. 45, Trudhesa
Activates 5-HT1B/1D receptors on intracranial vessels, causing vasoconstriction that blocks pulsatile pain afferents in migraine. Alpha-adrenergic activity adds peripheral vasoconstriction. Metabolised by CYP3A4 – strong CYP3A4 inhibitors (macrolides, azoles, ritonavir, cobicistat) raise concentration manifold and risk fatal ergotism.
Third line
Dihydroergotamine is a third-line option for acute migraine when triptans failed or are contraindicated. SEN reserves it for backup use. Available as nasal spray (Migranal), subcutaneous or intramuscular injection. Onset 30 minutes to 2 hours. Maximum 3 mg/day and 6 mg/week.
4 pairs found. Sorted from critical to minor.
Mechanism
Clarithromycin inhibits CYP3A4 – dihydroergotamine accumulates 5-10 fold. Fatal ergotism.
Symptoms
Limb ischaemia, myocardial infarction.
Management
Combination contraindicated.
Mechanism
Strongest CYP3A4 inhibitor – dihydroergotamine rises 20+ fold.
Symptoms
Fatal ergotism.
Management
Combination contraindicated.
Mechanism
Ritonavir is the strongest ARV CYP3A4 inhibitor. Fatal ergotism.
Symptoms
Digital ischaemia, stroke.
Management
Combination contraindicated.
Mechanism
Both are 5-HT1B/1D vasoconstrictors. Additive coronary and peripheral vasospasm. – at least 24-hour washout.
Symptoms
Myocardial ischaemia, stroke within hours.
Management
Combination contraindicated. At least 24 hours between doses.
Opens the checker prefilled with this drug. Pick the second one from your regimen.
Contraindicated in pregnancy: triggers uterine contraction and reduces uteroplacental blood flow.
Passes into milk. Breastfeeding not recommended.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
Dihydroergotamine is evaluated for the following indications with varying evidence strength: Acute migraine attack (evidence tier B). See the full indication matrix with dosing and citations above on this page.
Common side effects of Dihydroergotamine (≥ 1 in 100): Nausea, vomiting, Nasal congestion, Paresthesia, Muscle cramps. See the Safety section for uncommon and serious reactions.
FDA category X. Contraindicated in pregnancy: triggers uterine contraction and reduces uteroplacental blood flow.
Passes into milk. Breastfeeding not recommended.
Dihydroergotamine is contraindicated in: Pregnancy, breastfeeding; Strong CYP3A4 inhibitors (clarithromycin, itraconazole, ritonavir, cobicistat); Triptans within 24 hours; Ischemic heart disease; Uncontrolled hypertension. Full list in the Safety section.